Action T4 (German: Aktion T4) was the name used after World War II for Nazi Germany's "Euthanasia programme" during which physicians murdered thousands of people who were "judged incurably sick, by critical medical examination". The programme officially ran from September 1939 to August 1941, but it continued unofficially until the end of the Nazi regime in 1945.
During the official stage of Action T4, 70,273 people were killed, but the Nuremberg Trials found evidence that German and Austrian physicians continued the euthanization of patients after October 1941 and that about 275,000 people were murdeered under T4. More recent research based on files recovered after 1990 gives a figure of at least 200,000 physically or mentally handicapped people killed by medication, starvation, or in the gas chambers between 1939 and 1945.
The name T4 was an abbreviation of Tiergartenstraße 4, the address of a villa in the Berlin borough of Tiergarten which was the headquarters of the Gemeinnützige Stiftung für Heil- und Anstaltspflege, bearing the euphemistic name literally translating into English as "Charitable Foundation for Curative and Institutional Care". This body operated under the direction of Reichsleiter Philipp Bouhler, the head of Hitler's private chancellery, and Dr. Karl Brandt, Hitler's personal physician. This villa no longer exists, but a plaque set in the pavement on Tiergartenstraße marks its location.
In October 1939, Hitler signed a back-dated "euthanasia decree" to 1 September 1939 which authorised Bouhler and Brandt to carry out the programme of euthanasia (translated into English as follows):
"Reich Leader Bouhler and Dr. med. Brandt are charged with the responsibility of enlarging the competence of certain physicians, designated by name, so that patients who, on the basis of human judgment [menschlichem Ermessen], are considered incurable, can be granted mercy death [Gnadentod] after a discerning diagnosis."
The T4 programme is thought to have developed from the Nazi Party's policy of "racial hygiene", the belief that the German people needed to be "cleansed" of "racially unsound" elements, which included people with disabilities. According to this view, the euthanasia programme represents an evolution in policy toward the later holocaust of the Jews of Europe.
Racial hygienist ideas were far from unique to the Nazi movement. The ideas of social Darwinism were widespread in all western countries in the early 20th century, and the eugenics movement had many followers among educated people, being particularly strong in the United States. The idea of sterilising those carrying hereditary defects or exhibiting what was thought to be hereditary antisocial behaviour was widely accepted, and was put into law in the United States, Sweden, Switzerland and other countries. For example, between 1935 and 1975, 63,000 people were sterilised on eugenic grounds in Sweden.
The idea of enforcing "racial hygiene" had been an essential element of Hitler's ideology from its earliest days. In his book Mein Kampf (1924), Hitler wrote:
- He who is bodily and mentally not sound and deserving may not perpetuate this misfortune in the bodies of his children. The völkische [people's] state has to perform the most gigantic rearing-task here. One day, however, it will appear as a deed greater than the most victorious wars of our present bourgeois era.
The Nazi regime began to implement "racial hygienist" policies as soon as it came to power. The July 1933 "Law for the Prevention of Hereditarily Diseased Offspring" prescribed compulsory sterilisation for people with a range of conditions thought to be hereditary, such as schizophrenia, epilepsy, Huntington's chorea and "imbecility". Sterilisation was also mandated for chronic alcoholism and other forms of social deviance. This law was administered by the Interior Ministry under Wilhelm Frick through special Hereditary Health Courts (Erbgesundheitsgerichte), which examined the inmates of nursing homes, asylums, prisons, aged care homes and special schools to select those to be sterilised.
It is estimated that 360,000 people were sterilised under this law between 1933 and 1939. There were some suggestions that the programme should be extended to people with physical disabilities, but such ideas had to be expressed carefully, given that one of the most powerful figures of the regime, Joseph Goebbels, had a deformed right leg. Philipp Bouhler himself was mobility impaired as a result of war wounds to his legs. After 1937, the acute shortage of labour in Germany arising from the crash rearmament programme meant that anyone capable of work was deemed to be "useful" and was exempted from the law, and the rate of sterilisation declined.
The taking of thousands of brains from euthanasia victims demonstrated the way research was connected to the medical killings.
Although officially started in September 1939, Action T4 might have been initiated with a sort of trial balloon; in late 1938, Adolf Hitler instructed his personal physician Karl Brandt to evaluate a family's petition for the "mercy killing" of their blind, physically and developmentally disabled infant boy. The boy was eventually killed in July 1939. Hitler also instructed Brandt to proceed in the same manner in similar cases. The foundation of the Reich Committee for the Scientific Registering of Hereditary and Congenital Illnesses in order to prepare and proceed with the massive secret killing of infants took place in May 1939 and the respective secret order to start the registration of ill children, took place on 18 August 1939, three weeks after the murder of the mentioned boy.
Hitler was in favour of killing those whom he judged to be "unworthy of life". In a 1939 conference with health minister Leonardo Conti and the head of the Reich Chancellery, Hans Lammers, a few months before the euthanasia decree, Hitler gave as examples of "life unworthy of life" severely mentally ill people who he believed could only be bedded on sawdust or sand because they "perpetually dirtied themselves", or who "put their own excrement into their mouths, eating it and so on".
Both his physician, Dr. Karl Brandt, and the head of the Reich Chancellery, Hans Lammers, testified after the war that Hitler had told them as early as 1933, at the time the sterilisation law was passed, that he favoured killing the incurably ill, but recognised that public opinion would not accept this. In 1935, Hitler told the Reich Doctors' Leader, Dr. Gerhard Wagner, that the question could not be taken up in peacetime: "Such a problem could be more smoothly and easily carried out in war", he said. He intended, he wrote, "in the event of a war radically to solve the problem of the mental asylums". The outbreak of war thus opened up for Hitler the possibility of carrying out a policy he had long favoured.
The war also gave this issue a new urgency in the eyes of the Nazi regime. People with severe disabilities, even when sterilised, still needed institutional care. They occupied places in facilities which, during war, would be needed for wounded soldiers and people evacuated from bombed cities. They were housed and fed at the expense of the state, and took up the time of doctors and nurses. The Nazis barely tolerated this even in peacetime, and few would continue to support allowing it in wartime, especially in the last years of World War II when conditions overall were so terrible in Germany. As a leading Nazi doctor, Dr. Hermann Pfannmüller, said: "The idea is unbearable to me that the best, the flower of our youth must lose its life at the front in order that feebleminded and irresponsible asocial elements can have a secure existence in the asylum".
Even before the Nazis came to power, the German eugenics movement had an extreme wing, led by Alfred Hoche and Karl Binding, who as early as 1920 had advocated killing those with lives judged to be "life unworthy of life" (lebensunwertes Leben). Germany in the years after World War I was particularly susceptible to ideas of this kind. They interpreted Darwinism to suggest that a nation must promote the propagation of "beneficial" genes and prevent the propagation of "harmful" ones. Lifton notes: "The argument went that the best young men died in war, causing a loss to the Volk of the best available genes. The genes of those who did not fight (the worst genes) then proliferated freely, accelerating biological and cultural degeneration". The government, the eugenicists argued, must intervene to prevent this.
These views had gained ground after 1930, when the Depression caused sharp cuts in funding to state mental hospitals, creating squalor and overcrowding. Most German eugenicists were already strongly nationalist and anti-Semitic, and embraced the Nazi regime with enthusiasm. Many were appointed to positions in the Health Ministry and German research institutes, and their ideas were gradually adopted by the majority of the German medical profession, from which Jewish and communist doctors were soon purged.
During the 1930s, the Nazi Party carried out a campaign of propaganda in favour of "euthanasia". The National Socialist Racial and Political Office (NSRPA) produced leaflets, posters and short films to be shown in cinemas, pointing out to Germans the cost of maintaining asylums for the incurably ill and insane. These films included The Inheritance (Das Erbe, 1935), The Victim of the Past (Opfer der Vergangenheit, 1937), which was given a major premiere in Berlin and was shown in all German cinemas, and I Accuse (Ich klage an, 1941), which was based on a novel by Dr Hellmuth Unger, a consultant for the child euthanasia program. Catholic institutions, which could be expected to bitterly resist the killing of their patients, were progressively closed and their inmates transferred to already overcrowded state institutions, where the squalid conditions provided further ammunition for campaigns in favour of euthanasia.
Killing of children 
There were six psychiatric extermination centres: Bernburg, Brandenburg, Grafeneck, Hadamar, Hartheim, and Sonnenstein. They played a crucial role in developments leading to the Holocaust.
In the summer of 1939, the parents of a severely deformed child (identified in 2007 as Gerhard Kretschmar), born near Leipzig, wrote to Hitler seeking his permission for their child to be put to death. Hitler approved this and authorized the creation of the Reich Committee for the Scientific Registering of Serious Hereditary and Congenital Illnesses (Reichsausschuss zur wissenschaftlichen Erfassung erb- und anlagebedingter schwerer Leiden), headed by Karl Brandt, his personal physician, and administered by Herbert Linden of the Interior Ministry and SS-Oberführer, Viktor Brack. Brandt and Bouhler were authorized to approve applications to kill children in similar circumstances, though Bouhler left the details to subordinates, such as SA-Oberführer Werner Blankenburg and Brack.
This precedent was used to establish a programme of killing children with severe disabilities from which the 'guardian' consent element soon disappeared. From August, the Interior Ministry required doctors and midwives to report all cases of newborns with severe disabilities. Those to be killed were "all children under three years of age in whom any of the following 'serious hereditary diseases' were 'suspected': idiocy and Down syndrome (especially when associated with blindness and deafness); microcephaly; hydrocephaly; malformations of all kinds, especially of limbs, head, and spinal column; and paralysis, including spastic conditions". The reports were assessed by a panel of medical experts, of whom three were required to give their approval before a child could be killed.
Various methods of deception were used to gain consent – particularly in Catholic areas, where parents were generally uncooperative. Parents were told that their children were being sent to "Special Sections" for children, where they would receive improved treatment. The children sent to these centres were kept for "assessment" for a few weeks and then killed by injection of toxic chemicals, typically phenol; their deaths were recorded as "pneumonia". Autopsies were usually performed, and brain samples were taken to be used for "medical research." This apparently helped to ease the consciences of many of those involved, since it gave them the feeling that the children had not died in vain, and that the whole programme had a genuine medical purpose.
Once war broke out in September 1939, the programme adopted less rigorous standards of assessment and a quicker approval process. It expanded to include older children and adolescents. The conditions covered also expanded and came to include "various borderline or limited impairments in children of different ages, culminating in the killing of those designated as juvenile delinquents. Jewish children could be placed in the net' primarily because they were Jewish; and at one of the institutions, a special department was set up for 'minor Jewish-Aryan half-breeds'". At the same time, increased pressure was placed on parents to agree to their children's being sent away. Many parents suspected what was really happening, especially when it became apparent that institutions for children with disabilities were being systematically cleared out, and refused consent. The parents were warned that they could lose custody of all their children and if that did not suffice, the parents themselves could be threatened with call-up for "labour duty". By 1941, over 5,000 children had been killed. The last child to be killed under Action T4 was Richard Jenne on 29 May 1945 in the children's ward of the Kaufbeuren-Irsee state hospital in Bavaria, Germany, more than three weeks after troops from the U.S. had occupied the town.
Killing of adults 
Brandt and Bouhler soon developed plans to expand the programme to adults. In July 1939, they held a meeting attended by Dr. Leonardo Conti, Reich Health Leader and state secretary for health in the Interior Ministry, and Professor Werner Heyde, head of the SS medical department. This meeting had made preliminary arrangements for a national register of all institutionalised people with mental illnesses or physical disabilities.
The first adults with disabilities to be killed by the Nazi regime, however, were not Germans, but Poles, as the SS men of Einsatzkommando 16 cleared the hospitals and mental asylums of the Wartheland, a region of western Poland which was earmarked for incorporation into Germany and resettlement by ethnic Germans following the German conquest of Poland. In the Danzig (now Gdańsk) area, some 7,000 Polish inmates of various institutions were shot, while 10,000 were killed in the Gdynia area. Similar measures were taken in other areas of Poland destined for incorporation into Germany. At Posen (occupied Poznań), hundreds of patients were killed by means of carbon monoxide gas in an improvised gas chamber developed by Dr Albert Widmann, chief chemist of the German Criminal Police (Kripo). In December 1939, the SS head, Heinrich Himmler, witnessed one of these gassings, ensuring that this invention would later be put to much wider uses.
The idea of killing "useless" mental patients soon spread from occupied Poland to adjoining areas of Germany itself, probably because Nazi Party and SS officers in these areas were most familiar with what was happening in Poland. These were also the areas where Germans wounded from the Polish campaign were expected to be accommodated, creating a demand for hospital space. The Gauleiter of Pomerania, Franz Schwede-Coburg, dispatched 1,400 patients from five Pomeranian hospitals to Poland, where they were shot. The Gauleiter of East Prussia, Erich Koch, likewise had 1,600 patients killed. In all, more than 8,000 Germans were killed in this initial wave of killings. These were carried out on the initiative of local officials, although Himmler certainly knew and approved of them.
The programme for killing adults with mental or physical disabilities began with a letter from Hitler issued in October 1939. The letter charged Bouhler and Brandt with "enlarging the authority of certain physicians, to be designated by name, in such a manner that persons who, according to human judgement, are incurable, can, upon a most careful diagnosis of their condition of sickness, be accorded a mercy death." The letter was backdated to 1 September to provide legality to the killings already carried out, and to link the programme more definitely to the war, giving it a rationale of wartime necessity. This letter, which provided the sole legal basis for the programme, was not a formal "Führer decree", which in Nazi Germany had the force of law. For this reason Hitler deliberately bypassed Health Minister Conti and his department, who were held to be not sufficiently imbued with National Socialist ruthlessness and who might have raised awkward questions about the legality of the programme, and entrusted it to his personal agents Bouhler and Brandt.
The programme was administered by Brack's staff from Tiergartenstraße 4, under the guise of the Charitable Foundation for Cure and Institutional Care, supervised by Bouhler and Brandt. Others closely involved included Dr Herbert Linden, who had been heavily involved in the children's programme, Dr Ernst-Robert Grawitz, chief physician of the SS, and August Becker, an SS chemist. These officials chose the doctors who were to carry out the operational part of the programme. They were chosen for their political reliability, professional reputation, and known sympathy for radical eugenics. They included several who had proved their worth in the child-killing programme, such as Unger, Heinze, and Hermann Pfannmüller. The new recruits were mostly psychiatrists, notably Professor Carl Schneider of Heidelberg, Professor Max de Crinis of Berlin and Professor Paul Nitsche from the Sonnenstein state institution. Heyde became the operational leader of the programme, succeeded later by Nitsche.
In early October all hospitals, nursing homes, old-age homes, sanatoria were required to report all patients who had been institutionalised for five years or more, who had been committed as "criminally insane", who were of "non-Aryan race", or who had been diagnosed with any of a list of specified conditions. These included schizophrenia, epilepsy, Huntington's chorea, advanced syphilis, senile dementia, paralysis, encephalitis and "terminal neurological conditions generally". Many doctors and administrators assumed that the purpose of the reports was to identify inmates who were capable of being drafted for "labour service". They therefore tended to overstate the degree of incapacity of their patients, to protect them from labour conscription — with fatal consequences. When some institutions refused to co-operate, teams of T4 doctors (or in some cases Nazi medical students) visited them and compiled their own lists, sometimes in a very haphazard and ideologically motivated way. At the same time, all Jewish patients were removed from institutions and were killed during 1940.
As with the child inmates, the adults had their cases assessed by a panel of experts, working at the Tiergartenstraße offices. The experts were required to make their judgments solely on the basis of the reports, rather than on detailed medical histories, let alone examinations. Sometimes they dealt with hundreds of reports at a time. On each they marked a + (meaning death), a - (meaning life), or occasionally a ? meaning that they were unable to decide. Three "death" verdicts condemned the person concerned. As with the children, over time these processes became less rigorous, the range of conditions considered unsustainable grew broader, and zealous Nazis further down the chain of command increasingly made decisions on their own initiative.
At first patients were killed by lethal injection, the method established for killing children, but the slowness and inefficiency of this method for killing adults, who needed larger doses of increasingly scarce and expensive drugs and who were more likely to need restraint, was soon apparent. Hitler himself recommended to Brandt that carbon monoxide gas be used. At his trial, Brandt described this as a "major advance in medical history". The first gassings took place at Brandenburg Euthanasia Centre in January 1940, under the supervision of Widmann, Becker, and Christian Wirth, a Kripo (criminal police) officer who was later to play a prominent role in the "final solution" extermination of the Jews. Viktor Brack was head of these operations. 
Once the efficacy of this method was established, it became standardised and was instituted at a number of centres across Germany. As well as Brandenburg, these included Grafeneck Castle in Baden-Württemberg (10,824 dead), Schloss Hartheim near Linz in Austria (over 8,000 dead), Sonnenstein Euthanasia Centre in Saxony (15,000 dead), Bernburg Euthanasia Centre in Saxony-Anhalt and Hadamar Euthanasia Centre in Hesse (14,494 dead). As well as killing patients from mental homes, nursing homes and sanatoria, these centres were also used to kill prisoners transferred from concentration camps in Germany and Austria.
Patients were transferred from their institutions to the killing centres in buses operated by teams of SS men wearing white coats to give an air of medical authenticity called the Community Patients Transports Service. To prevent the families and the doctors of the patients tracing them, they were often sent to transit centres in major hospitals where they were supposedly assessed before being moved again to "special treatment" (Sonderbehandlung) centres. (The expression was later widely employed as a euphemism for killing during the extermination of the Jews.) Families were sent letters explaining that owing to wartime regulations it would not be possible to visit relatives in these centres. In fact most of these patients were killed within 24 hours of arriving at the centres, and their bodies cremated. For every person killed, a death certificate was prepared, giving a false but plausible cause of death, and sent to the family along with an urn of ashes (random ashes, since the victims were cremated en masse). The preparation of thousands of falsified death certificates in fact took up most of the working day of the doctors who operated the centres.
During 1940, the centres at Brandenburg, Grafeneck and Hartheim killed nearly 10,000 people each, while another 6,000 were killed at Sonnenstein. In all about 35,000 people were killed in T4 operations that year. Operations at Brandenburg and Grafeneck were wound up at the end of the year, partly because the areas they served had been cleared and partly because of public opposition. In 1941, however, the centres at Bernburg and Sonnenstein increased their operations, while Hartheim (where Wirth and Franz Stangl were successively commandants) continued as before. As a result, another 35,000 people were killed before August 1941, when the T4 programme was shut down. Even after that date, however, the centres continued to be used to kill concentration camp inmates: eventually some 20,000 people in this category were killed.
In 1971 the Austrian-born journalist Gitta Sereny conducted a series of interviews with Franz Stangl, who was in prison in Düsseldorf after having been convicted of co-responsibility for killing 900,000 people as commandant of the Sobibor and Treblinka extermination camps in Poland. Stangl gave Sereny a detailed account of the operations of the T4 programme based on his time as commandant of the killing facility at the Hartheim institute. He described how the inmates of various asylums were removed and transported by bus to Hartheim. Some were in no mental state to know what was happening to them, but many were perfectly sane and for them various forms of deception were used. They were told they were at a special clinic where they would receive improved treatment, and were given a brief medical examination on arrival. They were then induced to enter what appeared to be a shower block, where they were gassed with carbon monoxide (this ruse was later used on a much larger scale at the extermination camps).
Victim numbers 
|Number of victims of Action T4 (official data)
1940 – September 1941
|T4 Center||operation||number of victims|
|Grafeneck||20 January 1940||December 1940||9,839||---||9,839|
|Brandenburg||8 February 1940||October 1940||9,772||---||9,772|
|Bernburg||21 November 1940||30 July 1943||---||8,601||8,601|
|Hartheim||6 May 1940||December 1944||9,670||8,599||18,269|
|Sonnenstein||June 1940||September 1942||5,943||7,777||13,720|
|Hadamar||January 1941||31 July 1942||---||10,072||10,072|
|Source: Document 87, P. 232 cit. in Ernst Klee. Dokumente zur “Euthanasie”, 1985.|
Hitler and his aides were aware from the start that a programme of killing large numbers of Germans with disabilities would be unpopular with the German public. Although Hitler had a fixed policy of not issuing written instructions for policies relating to what would later be classed by the United Nations and other parties as crimes against humanity, he made an exception when he provided Bouhler and Brack with written authority for the T4 programme in his confidential October 1939 letter. This was apparently to overcome opposition within the German state bureaucracy – the Justice Minister, Franz Gürtner, needed to be shown Hitler's letter in August 1940 to gain his cooperation.
Hitler told Bouhler at the outset that "the Führer's Chancellery must under no circumstances be seen to be active in this matter." There was a particular need for caution in Catholic areas, which after the annexations of Austria and the Sudetenland in 1938 included nearly half the population of Greater Germany, and where public opinion could be expected to be hostile. In March 1940 a confidential report from the SD in Austria warned that the killing programme must be implemented with stealth "in order to avoid a probable backlash of public opinion during the war".
Opposition persisted within the bureaucracy. A district judge and member of the Confessing Church, Lothar Kreyssig, wrote to Gürtner protesting that the T4 programme was illegal (since no law or formal decree from Hitler had authorised it); Gürtner replied, "If you cannot recognise the will of the Führer as a source of law, then you cannot remain a judge." and had Kreyssig dismissed.
The Catholic Church had agreed to withdraw from all political activity in the Concordat of 1933 between Germany and the Holy See, but the prospect of state-sanctioned mass killing of German citizens had not occurred to the Church in 1933, and such a challenge to fundamental Christian belief in the sanctity of human life posed a serious dilemma for German Catholics. In 1935 the Church had protested in a private memorandum against proposals to pass a law legalising euthanasia: this was one reason the law was not enacted. August von Galen, the Bishop of Munster accused the government of breaking the law and publicly condemned the policy. Fr Bernhard Lichtenberg protested the policy to the Nazis chief medical officer. The regime took the program underground.
In January 1939, however, Brack commissioned a paper from Dr Joseph Mayer, Professor of Moral Theology at the University of Paderborn, on the likely reactions of the churches in the event of a state euthanasia programme being instituted. Mayer – a longstanding euthanasia advocate – reported that the churches would not oppose such a programme if it was seen to be in the national interest. Brack showed this paper to Hitler in July, and it may have increased his confidence that the "euthanasia" programme would be acceptable to German public opinion. (When Gitta Sereny interviewed Mayer shortly before his death in 1967, he denied that he had approved of killing people with disabilities, but since no copies of this paper are known to survive, this cannot be determined.) This turned out not to be the case. In fact the T4 programme was the sole example of an action by the Nazi regime which provoked large-scale public protests.
It was impossible to keep the T4 programme secret, given that thousands of doctors, nurses and administrators were involved in it, and given that the majority of those killed had families who were actively concerned about their welfare. Despite the strictest orders to maintain secrecy, some of the staff at the killing centres talked about what was going on there. In some cases families could tell that the causes of death notified were false, e.g. when a patient was claimed to have died of appendicitis, even though his appendix had been surgically removed some years earlier. In other cases several families in the same town would receive death certificates on the same day. In the towns where the killing centres were located, many people saw the inmates arrive in buses, saw the smoke from the crematoria chimneys, noticed that no bus-loads of inmates ever left the killing centres, and drew the correct conclusion. In Hadamar ashes containing human hair rained down on the town. In May 1941 the Frankfurt County Court wrote to Gürtner describing scenes in Hadamar where children shouted in the streets that people were being taken away in buses to be gassed.
During 1940 rumours of what was taking place spread, and many Germans withdrew their relatives from asylums and sanatoria to care for them at home – often with great expense and difficulty. In some places doctors and psychiatrists co-operated with families to have patients discharged, or, if the families could afford it, had them transferred to private clinics where the reach of T4 did not extend. Other doctors agreed to "re-diagnose" some patients so that they no longer met the T4 criteria, although this ran the risk of exposure when the Nazi zealots from Berlin conducted inspections. In Kiel, Professor Hans Gerhard Creutzfeldt managed to save nearly all of his patients. For the most part, however, doctors co-operated with the programme, either out of ignorance as to its true nature or out of agreement with Nazi eugenicist policies.
During 1940 protest letters began to arrive at the Reich Chancellery and the Ministry of Justice, some of them from Nazi Party members. The first open protest against the removal of people from asylums took place at Absberg in Franconia in February 1941, and others followed. The SD report on the incident at Absberg noted that "the removal of residents from the Ottilien Home has caused a great deal of unpleasantness", and described large crowds of Catholic townspeople, among them Party members, protesting against the action. Opposition to the T4 policy sharpened after the German attack on the Soviet Union in June 1941, because the war in the east produced for the first time large-scale German casualties, and the hospitals and asylums began to fill up with maimed and disabled young German soldiers. Rumours began to circulate that these men would also be subject to "euthanasia", although in fact no such plans existed.
Church action 
During 1940 and 1941 some Protestant churchmen protested privately against T4, but none made any public comment. Bishop Theophil Wurm, presiding the Evangelical-Lutheran Church in Württemberg, wrote a strong letter to Interior Minister Frick in March 1940. On 4 December 1940 Reinhold Sautter, Supreme Church Councillor of Württemberg's State Church, reproached the Nazi Ministerial Councillor Eugen Stähle for the murders in Grafeneck Castle, the latter then confronted him with the Nazi government opinion, that "The fifth commandment: Thou shalt not kill, is no commandment of God but a Jewish invention" and cannot claim any validity any more.
Others who privately protested were the Lutheran theologian Friedrich von Bodelschwingh, who was director of the Bethel Institution for epileptics at Bielefeld, and Pastor Paul-Gerhard Braune, director of the Hoffnungstal Institution near Berlin. Both used their connections with the regime to negotiate exemptions for their institutions: Bodelschwingh negotiated directly with Brandt and indirectly with Hermann Göring, whose cousin was a prominent psychiatrist. Braune had meetings with Justice Minister Gürtner, who was always dubious about the legality of the programme, and later wrote a strongly worded letter to Hitler protesting against it: Hitler did not read it, but was told about it by Lammers. In general, however, the Protestant church was more enmeshed with the Nazi regime than was the case for the Catholics and was unwilling to criticise its actions.
The Catholic Church, which since 1933 had pursued a policy of avoiding confrontation with the Nazi regime in the hope of preserving its core institutions intact, became increasingly unable to keep silent in the face of mounting evidence about the killing of inmates of hospitals and asylums. Leading Catholic churchmen, led by Cardinal Michael von Faulhaber of Munich, wrote privately to the government protesting against the policy. In July 1941 the Church broke its silence when a pastoral letter from the bishops was read out in all churches, declaring that it was wrong to kill (except in self-defence or in a morally justified war). This emboldened Catholics to make more outspoken protests.
A few weeks after the pastoral letter was read out, the Catholic Bishop of Münster in Westphalia, Clemens August Graf von Galen, publicly denounced the T4 programme in a sermon, and telegrammed his text to Hitler, calling on "the Führer to defend the people against the Gestapo". "It is a terrible, unjust and catastrophic thing when man opposes his will to the will of God", Galen said. "We are talking about men and women, our compatriots, our brothers and sisters. Poor unproductive people if you wish, but does this mean that they have lost their right to live?" Robert Lifton says of this sermon: "This powerful, populist sermon was immediately reproduced and distributed throughout Germany — indeed, it was dropped among German troops by British Royal Air Force pilots. Galen's sermon probably had a greater impact than any other statement in consolidating anti-'euthanasia' sentiment." Another Bishop, Franz Bornewasser of Trier, also sent protests to Hitler, though not in public. In August Galen was even more outspoken, broadening his attack to include the Nazi persecution of religious orders and the closing of Catholic institutions. He attributed the heavy allied bombing of Westphalian towns to the wrath of God against Germany for breaking His laws. Galen's sermons were not reported in the German press, but were widely circulated in the form of illegally printed leaflets. Local Nazis asked for Galen to be arrested, but Goebbels told Hitler that if this happened there would be an open revolt in Westphalia.
By August the protests had spread to Bavaria. According to Gitta Sereny, Hitler himself was jeered by an angry crowd at Hof – the only time he was opposed in public during his 12 years of rule. Despite his private fury, Hitler knew that he could not afford a confrontation with the Church at a time when Germany was engaged in a life-and-death war, a belief which was reinforced by the advice of Goebbels, Martin Bormann, head of the Party Chancellery, and Heinrich Himmler, head of the SS. Robert Lifton writes: "Nazi leaders faced the prospect of either having to imprison prominent, highly admired clergymen and other protesters — a course with consequences in terms of adverse public reaction they greatly feared — or else end the programme." Himmler said: "If operation T4 had been entrusted to the SS, things would have happened differently", because "when the Führer entrusts us with a job, we know how to deal with it correctly, without causing useless uproar among the people."
On 24 August 1941 Hitler ordered the cancellation of the T4 programme, and also issued strict instructions to the Gauleiters that there were to be no further provocations of the churches for the duration of the war. The invasion of the Soviet Union in June had opened up new opportunities for the T4 personnel, who were soon transferred to the east to begin work on a vastly greater programme of killing: the "final solution of the Jewish question". But the winding up of the T4 programme did not bring the killing of people with disabilities to an end, although from the end of 1941 the killing became less systematic. Lifton documents that the killing of both adults and children continued to the end of the war, on the local initiative of institute directors and party leaders. The methods reverted to those employed before the gas chambers were employed: lethal injection, or simple starvation. Kershaw estimates that by the end of 1941 75,000 to 100,000 people had been killed as a result of the programme, but that further tens of thousands of concentration camp inmates, and people judged incapable of work, were killed in Germany between 1942 and 1945 (this figure does not include the Jews who were deported to their deaths in 1942 and 1943). Hartheim, for example, continued to kill people sent to it from all over Germany until 1945.
Postwar legacy 
The Doctors' Trial 
In December 1946, an American military tribunal (commonly called the Doctors' Trial) tried 23 doctors and administrators for their roles in war crimes and crimes against humanity. These crimes included the systematic killing of those deemed "unworthy of life", including the mentally disabled, the institutionalized mentally ill, and the physically impaired. After 140 days of proceedings, including the testimony of 85 witnesses and the submission of 1,500 documents, in August 1947 the court pronounced 16 of the defendants guilty. Seven were sentenced to death and executed on 2 June 1948. They included Dr. Karl Brandt and Viktor Brack.
The indictment read in part:
14. Between September 1939 and April 1945 the defendants Karl Brandt, Blome, Brack, and Hoven unlawfully, willfully, and knowingly committed crimes against humanity, as defined by Article II of Control Council Law No. 10, in that they were principals in, accessories to, ordered, abetted, took a consenting part in, and were connected with plans and enterprises involving the execution of the so called "euthanasia" program of the German Reich, in the course of which the defendants herein murdered hundreds of thousands of human beings, including German civilians, as well as civilians of other nations. The particulars concerning such murders are set forth in paragraph 9 of count two of this indictment and are incorporated herein by reference.
Also in 1945, seven staff members of the Hadamar institute were tried for the killing of Soviet and Polish nationals, but not for the large-scale killing of German nationals at the institute. Alfons Klein, Karl Ruoff and Wilhelm Willig were sentenced to death and executed, the other four were given long prison sentences.
Others involved in the programme 
- August Becker, initially sentenced to three years after the war, then in 1960 was tried again and sentenced to 10 years in prison. He served very little of the later term because of an early release due to ill-health. He died in 1967.
- Werner Blankenburg, lived under an alias and died in 1957
- Philipp Bouhler, killed himself in captivity, May 1945.
- Leonardo Conti, hanged himself in captivity, October 6, 1945.
- Dr Ernst-Robert Grawitz killed himself shortly before the fall of Berlin in April 1945.
- Dr Herbert Linden, 1945, suicide. Overseers of the program were initially Herbert Linden and Werner Heyde. Linden was later replaced by Hermann Paul Nitsche... The Planning Department tried between May 1941 and October 1942 through spot checks to determine how the institutional capacities after the murder of the sick of the action T4 were reused. Central planning was often the responsibility of regional authorities. On 5 August 1942, a survey carried out among the competent authorities started by Dr Linden, how many asylum patients in corridors, common rooms, and chapels could be accommodated. In November 1942 Dr Linden ordered the twice-yearly survey of all psychiatric patients during Action T-4.
In his capacity as Reich Commissioner for the hospitals and nursing homes, Linden coordinated patients of the medical and nursing homes in Northern and Western Germany 1943. These areas were first affected by the allied air strikes. Arriving in the target institutions, these sick were preferred targets of killings in the Action Brandt, also called the second phase of Nazi euthanasia. Methods of killing were by drug overdose as well as the systematic malnutrition of patients. Linden endeavoured to fill directorships in institutions with supporters of further euthanasia. In 1943 it was important, he said, "that the psychiatrists increasingly turn to the idea of euthanasia from inner personal conviction." "In this respect currently the majority of current euthanasian doctors are even more in demand". And, it was "especially important to bring in reliable euthanasia psychiatrists into Directorships". (trans. from German) 
- Dr Fritz Cropp d. April 6, 1984, Bremen. He was a German physician and Nazi official. In 1933, in Oldenburg, Fritz Cropp was appointed the country medical officer of health. Two years later, in 1935, followed by his transfer to Berlin, where he worked as a ministerial adviser in the Division IV (health care and people care) in the Ministry of the Interior. In 1939, he became Assistant Director. Fritz Cropp was involved in the Nazi "euthanasia", the so-called action T-4, in 1940. He was Herbert Linden's superior. He was responsible for patient transfers.
- Werner Heyde, after having escaped detection for 18 years, killed himself in 1964 before being brought to trial.
- Dr Heinrich Gross was tried twice. One sentence was overturned and another was suspended; he died in 2005.
- Lorenz Hackenholt, vanished 1945.
- Erich Koch served time in prison from 1950 to his death in 1986.
- Erwin Lambert, died in 1976.
- Dr Friedrich Mennecke died in 1947 while awaiting trial.
- Philipp, Landgrave of Hesse, the governor of Hesse-Nassau, was not tried for his part in the T4 programme; he died in 1980.
- Paul Nitsche was tried and executed by an East German court in 1948.
- Professor Carl Schneider hanged himself in his prison cell in 1946, while awaiting trial.
- Franz Schwede was sentenced to 10 years in prison in 1948 and was pardoned in 1956; he died in 1960.
- Dr. Ernst Illing was the director of the Vienna Psychiatric-Neurological Clinic for Children Am Spielgrund, where he killed about 200 children, sentenced to death on July 18, 1946
- Dr. Marianne Türk, was a doctor at Vienna Psychiatric-Neurological Clinic for Children Am Spielgrund where together with Ernst Illing; she killed 200 children. She was sentenced to 10 years prison on July 18, 1946.
The Ministry for State Security of East Germany had around 30,000 files of the T4 project stored away in their archives. Those files became available to the public in 1990 German Reunification, this triggered a new wave of research.
See also 
- Nazi eugenics, the racially-based social policies that placed the improvement of the Aryan race at the heart of Nazis ideology.
- Elfriede Lohse-Wächtler, a notable German artist who was killed in a mental institution under Action T4.
- Operation Reinhard, the architects of Aktion T4 provided the expertise for building the extermination camps during the Holocaust.
- Bullenhuser Damm
- Killing centers
- Am Spiegelgrund clinic
- Bernburg Euthanasia Centre
- Brandenburg Euthanasia Centre
- Grafeneck Euthanasia Centre
- Hadamar Euthanasia Centre
- Hartheim Euthanasia Centre
- Soldau concentration camp
- Sonnenstein Euthanasia Centre
- Jewish skeleton collection
- Sandner (1999): 385 (66 in PDF) Note 2. The author claims the term Aktion T4 was not used by the Nazis but was first used in the trials against the doctors and later included in the historiography.
- Proctor (1988): 177
- Peter Longerich, Holocaust: The Nazi Persecution and Murder of the Jews, p.477 – note 44
- Browning (2005): p.193
- Lifton (1986): p. 95-96
- Lifton (1986): p.102
- Proctor (1988): p.191
- Estimated by objective evidence and condemned by the Nuremberg Military Tribunal and subsequently ratified many times, for example, recently by Ryan, Donna & Schuchman, John S. : p.62.
- Horst von Buttlar:Forscher öffnen Inventar des Schreckens at Spiegel Online (1 October 2003) (German)
- Sereny (1983): 48
- This was the Kanzlei des Führer der NSDAP, not to be confused with the Reich Chancellery or Reichskanzlei
- Miller (2007), 160
- Lifton (1986): 64
- Evans, 514
- Hitler, Mein Kampf, 447 (cited by Peter Padfield, Himmler, Macmillan 1990, 260)
- Evans, 507
- This was the result either of club foot or osteomyelitis. Goebbels is commonly said to have had club foot (talipes equinovarus), a congenital condition. William L. Shirer, who worked in Berlin as a journalist in the 1930s and was acquainted with Goebbels, wrote in The Rise and Fall of the Third Reich (1960) that the deformity was from a childhood attack of osteomyelitis and a failed operation to correct it.
- Evans (2005): 508
- Weindling, Paul Julian (2006). Nazi Medicine and the Nuremberg Trials: From Medical War Crimes to Informed Consent. Palgrave Macmillan. p. 6. ISBN 0-230-50700-X.
- Friedman (2011), p.146 note 12
- Stephen J. Cina, Joshua A. Perper, When Doctors Kill, p.59
- Lifton (1986): pp. 50–51
- [Proctor (1988): p.10]
- Lifton (1986): 62
- Kershaw, II, 256
- Lifton (1986): 63
- Their ideas were published in The Permission to Destroy Life Unworthy of Life (Die Freigabe der Vernichtung lebensunwerten Lebens), 1920
- Lifton (1986): 47
- Kershaw, II, 254
- The ready acceptance of Nazi ideas by the majority of the German medical profession is described in Evans, 444
- Lifton (1986): 48–49.
- Breggin, Peter (1993). "Psychiatry's role in the holocaust". International Journal of Risk & Safety in Medicine 4 (1993): 133–148.
- Fuller Torrey, Edwin; Yolken, Robert (January 2010). "Psychiatric genocide: Nazi attempts to eradicate schizophrenia". Schizophrenia Bulletin 36 (1): 26–32. doi:10.1093/schbul/sbp097. PMC 2800142. PMID 19759092. Retrieved 28 March 2012.
- Schmidt (2007): 118
- Lifton is of the view that this request was "encouraged", although the existence of the child and the agreement of the parents to its killing were apparently genuine (Lifton (1986): 50)
- Browning (2005): 185
- Kershaw, II, 259
- Miller (2007), 158
- Lifton (1986): 52
- These were Professor Werner Catel (a Leipzig psychiatrist), Professor Hans Heinze, head of a state institution for children with intellectual disabilities at Görden near Brandenburg, Ernst Wentzler a Berlin pediatric psychiatrist, the author Dr Helmut Unger. (Lifton (1986): 52)
- Sereny (1983): 55
- Lifton (1986): 60
- Lifton (1986): 56
- Lifton (1986): 55
- Browning, 190. Lifton concurs with this figure, but notes that the killing of children continued even after the T4 programme was formally ended in 1941.
- Henry Friedlander (1995). The Origins of Nazi Genocide: From Euthanasia to the Final Solution University of North Carolina Press, 1995. p. 163.
- Suzanne E. Evans. Forgotten crimes: the Holocaust and people with disabilities. p. 93. Retrieved 25 July 2011.
- Browning, 186–7.
- Browning, 188
- Browning, 190, Kershaw, II, 261
- Padfield, 261
- Kershaw, II, 253
- Lifton (1986): 64. Several drafts of a formal euthanasia law were prepared, but Hitler refused to authorise them. Thus the senior participants in the programme always knew that it was illegal even by the loose definition of legality prevailing in Nazi Germany.
- Lifton (1986): 66
- Lifton, 67
- Browning, 191, Padfield, 261, 303, Lifton (1986): 77. According to Lifton, most Jewish inmates of German mental institutions were dispatched to Lublin in Poland in 1940 and killed there.
- Lifton, 71
- Lifton (1986): 72
- George J. Annas, and Michael A. Grodin, The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation (Oxford: Oxford University Press, 1992), 25.
- Burleigh, Michael (2000): p.54
- Lifton (1986): 74
- These figures come from the article Aktion T4 on the German Wikipedia, which sources them to Ernst Klee, "Euthanasie" im SS-stadt: Die "Vernichtung lebensunwerten Leben" ("Euthanasia" in the SS-state: The extermination of "life unworthy of life"), Frankfurt 1983
- Sereny (1983): 41–90
- Padfield, 304
- Sereny (1983): 71
- Lifton (1986): 75
- Sereny (1983): 58
- Lifton (1986): 82. Creutzfeldt is also remembered as the co-discoverer of Creutzfeldt-Jakob disease
- Lifton (1986): 80. Lifton lists a handful of psychiatrists and administrators who actively resisted the T4 programme.
- Lifton (1986): 90
- Schmuhl (1987): p. 321
- Lifton (1986): 90–92.
- Sereny (1983): 69, 74
- Kershaw, II, 427
- Lifton (1986): 93
- Lifton (1986): 94
- Kershaw, II, 429
- Sereny (1983): 59. Sereny did not claim firsthand knowledge of this event. It is apparently based on testimony given by Dr Friedrich Mennecke during a postwar trial. According to Mennecke, Hitler was traveling between Munich and Berlin when his train suddenly stopped at a station. A crowd was watching a group of "retarded patients" being loaded into a train. Seeing Hitler at the window, the crowd became threatening. Mennecke apparently told this as an "anecdote" rather than something he knew to be true.
- Lifton (1986): footnote 1
- Lifton (1986): 95
- Lifton (1986): 96–102.
- "Transcription". United States Holocaust Museum.
- "Captured German Records" (PDF). Archives.
- Draft of a letter to the President of the regional chapter of the Bavarian Palatinate from 1943, Richard Imbt, quoted in sweet, "Body politic", S. 355.
- Ernst Klee: Fritz Cropp, Eintrag in ders.: Das Personenlexikon zum Dritten Reich. Wer war was vor und nach 1945. Aktualisierte Ausgabe. Fischer-Taschenbuch-Verlag, Frankfurt am Main 2005, ISBN 3-596-16048-0, S. 98
- Berenbaum: p.247
- Totten & Parsons (2009): 181 ss.
- Bachrach, Susan D; Kuntz, Dieter; United States Holocaust Memorial Museum (2004). Deadly Medicine: Creating the Master Race.. Washington D.C.:United States Holocaust Memorial Museum: Chapel Hill, NC : Distributed by the University of North Carolina Press. ISBN 0-8078-2916-1.
- Benzenhöfer, Udo (2010). Euthanasia in Germany Before and During the Third Reich. Münster/Ulm: de:Verlag Klemm & Oelschläger. ISBN 978-3-86281-001-7.
- Berenbaum, Michael; Peck, Abraham J. Review: The Holocaust and history.
- Browning, Christopher (2005). The Origins of the Final Solution: The Evolution of Nazi Jewish Policy, September 1939 – March 1942. Arrow. ISBN 978-0-8032-5979-9.
- Burleigh, Michael (1995). Death and Deliverance: 'Euthanasia' in Germany 1900–1945. New York: Verlag Klemm + Oelschläger.
- Burleigh, M. & Wippermann, W. (1991). The Racial State: Germany 1933–1945. Cambridge University Press.
- Burleigh, Michael (2000). "Psychiatry, German Society and the Nazi "Euthanasia" Programme". In Omer Bartov. The Holocaust Origins, Implementation, Aftermath. London: Routledge. p. 54. ISBN 0-415-15036-1.
- Evans, Richard J. (2005). The Third Reich in Power. Allen Lane.
- Friedlander, Henry (1995). The Origins of Nazi Genocide. From Euthanasia to the Final Solution. University of North Carolina Press, Chapel Hill & London. ISBN 0-8078-2208-6.
- Friedman, Jonathan C. (2011). The Routledge History of the Holocaust. Routledge. p. 516. ISBN 0-203-83744-4.
- Klee, Ernst (1985). Dokumente zur Euthanasie (in German). Frankfurt am Main: Fischer Taschenbuch Verlag. ISBN 3-596-24327-0.
- Klee, Ernst (1983). Euthanasie im NS-Staat. Die Vernichtung lebensunwerten Lebens (in German). Frankfurt am Main: Fischer Taschenbuch Verlag. ISBN 3-596-24326-2.
- Klee, Ernst (1986). Was sie taten. Was sie wurden: Ärzte, Juristen und andere Beteiligte am Kranken- oder Judenmord (in German). Fischer Taschenbuch. p. 355. ISBN 3-596-24364-5.
- Lifton, Robert Jay MD (1986). The Nazi Doctors: Medical Killing and the Psychology of Genocide. Library of Congress. U.S.A. p. 561. ISBN 0-465-04904-4.
- Miller, Michael (2007). Leaders of the SS and German Police, Vol. 1, R. James Bender Publishing. ISBN 93-297-0037-3
- Ost, Suzanne (April 2006). "Doctors and nurses of death: a case study of eugenically motivated killing under the Nazi 'euthanasia' programme". Liverp Law Rev 27 (1): 5–30. doi:10.1007/s10991-005-5345-2. PMID 17340766.
- Padfield, Peter (1990). Himmler: Reichsführer-SS. Macmillan. ISBN 978-0333404379.
- Proctor, Robert N. (1988). Racial Hygiene: Medicine under the Nazis. Library of Congress: Harvard College. p. 414. ISBN 0-674-74578-7.
- Ryan, Donna F. & Schuchman, John S. (2002). Racial Hygiene: Deaf People in Hitler's Europe. Gallaudet University Press. ISBN 978-1-56368-132-5.
- Sandner, Peter (July 1999). "Die "Euthanasie"-Akten im Bundesarchiv. Zur Geschichte eines lange verschollenen Bestandes". Vierteljahrschefte für Zeitgeschichte – Institut für Zeitgeschichte (Munich, Germany)) 47 (3): 385–400. ISSN 0042-5702.
- Schmidt, Ulf (2007). Karl Brandt: The Nazi Doctor. Hambledon Continuum.
- Schmuhl, Hans-Walter (1987). Rassenhygiene, Nationalsozialismus, Euthanasie: Von der Verhütung zur Vernichtung "lebensunwerten Lebens", 1890–1945 (Kritische Studien zur Geschichtswissenschaft Bd. 75) (in German). Göttingen: Vandenhoeck & Ruprecht,. p. 526. ISBN 3-525-35737-0.
- Note: simultaneously handed in as doctoral thesis in Bielefeld, University of Bielefeld, Diss., 1986 under the title: Die Synthese von Arzt und Henker
- Sereny, Gitta (1983). Into that darkness: an examination of conscience. Vintage Books. p. 379. ISBN 978-0394710358.
- Werthman, Fredric (1967). A Sign for Cain. New York: MacMillan and Company. ISBN 978-0026259705.
- Thompson, D. (2004). "Axis History Forum. The Nazi Euthanasia Program".
- Totten, Samuel; Parsons, William S. (2009). Century of genocide: critical essays and eyewitness accounts (Third ed.). New York: Routledge. ISBN 978-0-415-99084-4.
- BBC; The Nazis: A Warning from History, television documentary 1997
- Domino Films / Channel 4 (UK television): Selling Murder: The Killing Films of the Third Reich, dir. Joanna Mack, Channel 4, tx. 22 October 1991: includes excerpts from Opfer der Vergangenheit and Ich Klage An.
- * Astrid Ley, Annette Hinz-Wessels (editors): The “Euthanasia Institution” of Brandenburg an der Havel. - Murder of the ill and handicapped during National Socialism. www.metropol-verlag.de, ISBN 978-3-86331-086-8
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